Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA 02111
www.mass.gov/masshealth
MassHealth
Durable Medical Equipment Bulletin 14
April 2008
TO: Durable Medical Equipment Providers Participating in MassHealth
FROM: Tom Dehner, Medicaid Director
RE: Clarification of Coverage of Formulas (Enteral-Nutrition Products)
Background
This bulletin clarifies coverage of certain enteral-nutrition products for
MassHealth members who may also be eligible for enteral-nutrition
products provided by the Department of Public Health’s (DPH) Women,
Infants and Children (WIC) nutrition program. WIC may refer to enteral-
nutrition products as “special,” “prescription,” or “regular” formulas.
Members who may qualify for the WIC program include pregnant,
postpartum, and breastfeeding women, infants, and children under the
age of five.
Enteral Nutrition Covered by WIC
The table below reflects the enteral-nutrition products that WIC covers.
For these products, MassHealth is payer of last resort. Providers may contact the
DPH WIC help line at 1-800-WIC-1007 for further information on limits or
other coverage information.
Formula
Type Available*
Good Start Supreme DHA/ARA
P, C, R
Good Start Supreme Soy DHA/ARA
P, C, R
Good Start Supreme
P
Enfamil Lipil with Iron
P, C, R
Enfamil Lipil Low Iron
P, R
ProSobee Lipil
P, C, R
*P= Powder
C= Concentrate
R= Ready to use
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Enteral Nutrition not Covered by WIC
MassHealth(including its contracted Managed Care Organizations
((MCOs)) has primary responsibility for payment of enteral-nutrition
products that are not on the above list of enteral-nutrition products
covered by WIC for MassHealth members who are eligible to receive
enteral nutrition through the WIC program.
General PA Requirements for Enteral Nutrition
MassHealth covers enteral-nutrition products that are medically
necessary in accordance with 130 CMR 450.204. All enteral-nutrition
products are provided as a DME benefit and require prior authorization
(PA). MassHealth DME providers and pharmacy providers with a DME specialty
must submit prior-authorization requests in accordance with Appendix A of
the All Provider Manual. In addition, a signed prescription and written
documentation of medical necessity from the member’s physician or nurse
practitioner must accompany the prior-authorization request in accordance
with the DME regulations at 130 CMR 409.000. NOTE: PA requests for
enteral-nutrition products for MCO members must be processed by the
respective MCO.
PA Requirements for Enteral-Nutrition Products not Covered by WIC
If the PA request is for an enteral-nutrition product that is not
on the above list of enteral-nutrition products covered by WIC,
and the member may qualify for WIC as described in the first
paragraph above, MassHealth will process the PA request with
the above medical documentation, and no proof of WIC eligibility
is needed.
PA Requirements for Enteral-Nutrition Products Covered by WIC
If the PA request is for an enteral-nutrition product that
is on the above list of enteral-nutrition products covered by
WIC, and the member may qualify for WIC as described in the
first paragraph above, MassHealth requires proof of the member’s
WIC eligibility. Providers must obtain from the member WIC
documentation that the member is either WIC eligible or WIC
ineligible, and submit this documentation along with the PA
request and the required medical documentation. If MassHealth
does not receive this documentation with the PA request for
enteral nutrition, MassHealth may defer or deny the PA request.
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PA Requirements (cont.) Upon receipt of a completed PA request for an
enteral-nutrition product that is on the above list of enteral-nutrition
products covered by WIC, MassHealth will determine that the member is:
1. WIC eligible and will receive enteral nutrition sufficient to meet the
member’s medical need through WIC (note that in the absence of a
demonstrated need, MassHealth will deny the PA);
2. WIC ineligible and enteral nutrition will not be provided by WIC; or
3. WIC eligible, and the PA request is for enteral nutrition above the
amount that WIC will provide the member. In such cases, the PA
request must include the WIC documentation as well as medical
documentation from the member’s physician or nurse practitioner to
support the request for enteral nutrition beyond the amount
provided by WIC.
MassHealth will then process the PA request and approve, modify, or deny the
request and notify the member and the provider of its decision.
Service Codes and Descriptions
Providers should consult Subchapter 6 of the Durable Medical Equipment
Manual for information on service codes and descriptions for enteral-nutrition
products. Providers may also find service codes and descriptions in the DME and Oxygen
Payment and Coverage Guidelines Tool available on the MassHealth Web site at
www.mass.gov/masshealth. Go to MassHealth Regulations and Other Publications,
then Provider Library.
PA Guidelines
MassHealth has published Guidelines for Medical Necessity
Determination for Enteral Nutrition Products, which can be
viewed on MassHealth’s Web site at www.mass.gov/masshealth.
Click on Information for Providers, then MassHealth Provider Forms,
then Forms Used by Multiple Provider Types. MassHealth has also
published on its Web site the Medical Necessity Review Form for
Enteral Nutrition Products, which providers can download and use
when submitting requests for PA.
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Questions If you have any questions about the information in this bulletin,
please contact MassHealth Customer Service at 1-800-841-2900, e-mail your
inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.
For MassHealth MCO members, providers must contact the appropriate
MCO Customer Service Center listed below.
• Boston Medical Center Health Plan:1-888-566-0008 or 1-800-900-1451
• Fallon Community Health Plan: 1-866-275-3247
•
Network Health: 1-888-257-1985
• Neighborhood Health Plan: 1-800-462-5449